Scenario — Chest pain at the footy — suspected ACS in elderly male

intermediate Cardiac · Elderly · 75yr · male

Patient Information

Dispatch	You are called to an elderly male (Brian Carmichael, 75YO) seated in the grandstand at Optus Stadium. A bystander reports he has been complaining of chest tightness for the last 20 minutes and looks pale and unwell.
Patient	Brian Carmichael — 75yr (75kg)
Incident History	Pt was watching the AFL game with his son when he developed central chest tightness and pressure approximately 20 minutes ago. He initially thought it was indigestion but the pain has not settled with rest. He looks pale and is sweating.
Emergency Contact	David Carmichael (Son (present on scene)) — 0412 348 921

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Speaking in full sentences but short of breath.
Breathing	Slightly laboured. RR elevated. Nil audible wheeze or crackles.
Circulation	Radial pulse present — regular, moderate strength. Skin pale, cool and diaphoretic. Nil external bleeding.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Mild distress.
Exposure	No rashes, no visible trauma. Pt clutching centre of chest. Diaphoretic.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	95% (RA)	Mild	20	96	148/92	<2s	15	4 4 ++	36.9	6.4 mmol/L	7
10 mins	97% (O2 NRB 10L)	Nil	17	88	136/84	<2s	15	4 4 ++	36.9	6.4 mmol/L	4

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected Acute Coronary Syndrome (ACS) — likely NSTEMI or unstable angina — presenting with prolonged central chest pressure, radiation to the left shoulder and jaw, diaphoresis, and nausea in a 75-year-old male with known hypertension, Type 2 diabetes, and prior cardiac stent.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not ask about erectile dysfunction medications or PDE5 inhibitors before administering GTN — patient reveals he took sildenafil 'about 12 hours ago' — GTN is now contraindicated; trainees must withhold GTN and proceed to Methoxyflurane for analgesia.)
! (If trainees do not administer aspirin within 5 minutes — patient's pain escalates to 9/10 and he becomes increasingly distressed and diaphoretic; his SpO2 drops to 93% on room air.)
! (If oxygen is not applied within 3 minutes — SpO2 drops to 92% on room air and patient becomes more anxious and reports worsening breathlessness.)
! (If trainees fail to limit patient exertion or attempt to walk Brian to the FAP — patient becomes markedly diaphoretic and pale; pulse rises to 110 bpm.)
! (If trainees do not perform a full history including current medications — they may attempt to give a second aspirin dose; facilitator notes Brian already took aspirin 100mg this morning; current CPG states aspirin should still be administered even if taken that day — trainees must administer 300mg aspirin regardless.)
! (If pain remains >3/10 after 1 spray of GTN and trainees do not offer Methoxyflurane — patient states 'the pain is still really bad, can you do anything else?' to prompt consideration of analgesia.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm airway patent, breathing adequate, radial pulse present, GCS 15.
3. Position patient seated or semi-recumbent in current location — do NOT walk the patient to the FAP.
4. Perform Vital Sign Survey — HR, RR, BP, SpO2, BGL, temperature, pain score.
5. Apply oxygen via non-rebreather mask at 10–15 L/min — titrate to target SpO2 94–98%.
6. Obtain IMISTAMBO history — specifically ask about PDE5 inhibitor use (sildenafil, tadalafil, vardenafil, avanafil) before administering GTN.
7. Administer Aspirin 300mg oral (chewed or dissolved in small amount of water) — indicated for suspected ACS; administer even though patient took aspirin 100mg earlier today.
8. Confirm GTN is NOT contraindicated: SBP >90 mmHg ✓, HR 50–150 bpm ✓, no PDE5 inhibitor use in last 24 hours (sildenafil/vardenafil/avanafil) or 3 days (tadalafil) — confirm verbally with patient.
9. Administer GTN 400 microg (1 spray) sublingually — patient must be seated or semi-recumbent, do not shake bottle.
10. Reassess pain score and BP after 5 minutes.
11. If pain >3/10 after first GTN spray and no contraindications: administer second GTN spray 400 microg sublingually at 5-minute interval.
12. If pain remains >3/10 post GTN: administer Methoxyflurane (Penthrox) 3 mL via inhaler — patient self-administers; record pain score pre and post.
13. Administer Ondansetron 4 mg oral wafer if patient reports nausea or vomiting — may repeat after 15 minutes if remains symptomatic (max 8mg in 8 hours).
14. Record full observations every 10 minutes.
15. Request Priority 1 ambulance response immediately — do not delay for treatment completion.
16. Continuously reassure patient and keep son (David) informed.
17. Prepare for potential deterioration — position defibrillator (AED) nearby and be prepared to commence CPR if cardiac arrest occurs.
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chest Pain / Acute Coronary Syndrome · Glyceryl Trinitrate (GTN, Nitroglycerin) · Aspirin (Disprin, Disprin Direct, Aspro Clear) · Methoxyflurane (Penthrox) · Ondansetron · Oxygen

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Signs/Symptoms	Central chest tightness described as a heavy pressure. Associated mild shortness of breath, nausea and diaphoresis. No palpitations reported.
Allergies	NKDA — no known drug allergies.
Medications	Perindopril 5mg daily (hypertension). Atorvastatin 40mg nocte. Metformin 500mg BD (Type 2 diabetes). Aspirin 100mg daily (already taken this morning).
Pertinent History	Known hypertension and Type 2 diabetes. Previous cardiac stent inserted 6 years ago. Non-smoker. Denies use of sildenafil, tadalafil or any erectile dysfunction medications.
Last Oral Intake	Ate a meat pie and soft drink approximately 1 hour ago.
Events Leading	Pt was seated watching the AFL game. No physical exertion. Pain came on spontaneously and has not resolved with rest over 20 minutes.
Treatment Prior	Son gave him a sip of water. No other treatment prior to EHS arrival.

Onset	Sudden onset approximately 20 minutes ago while seated watching the game. No precipitating exertion.
Pain	Central chest — heavy, tight, crushing sensation.
Quality	Pressure-like, constant, not pleuritic.
Radiates	Radiates to left shoulder and jaw.
Severity	7/10 at rest.